Epidemiology of life-threatening and lethal anaphylaxis: a review
Anaphylaxis, a term first used by Richet and Portier in
1902, is a serious and potentially lethal systemic reaction
affecting two or more organs or systems (1). In English,
the term embraces all the immediate signs caused by the
release of active mediators from mast cells and basophils.
Severe anaphylaxis is characterized by four clinical
syndromes. Anaphylactic shock includes cardiovascular
collapse associated with cutaneous, respiratory or gas-
trointestinal signs. Serious acute asthma is a particular
type of anaphylaxis and is exemplified by lethal peanut
allergy (2). Laryngeal angio-oedema, either isolated or
associated with facial angio-oedema, is serious since it
may cause asphyxia. Finally, there may be a systemic
reaction affecting several target organs, with urticaria,
abdominal pain, vomiting and respiratory distress. Ana-
phylaxis may also be classified into four grades according
to severity (3, 4), severe anaphylaxis corresponding to
grades 3 and 4. Grade 3 includes such serious symptoms
as cardiovascular collapse, cardiac arrhythmia and severe
broncho-spasm. Grade 4 includes circulatory failure,
cardiac and/or respiratory arrest. Lethal anaphylaxis
could be graded as 5.
Prevalence of life-threatening anaphylaxis
The prevalence of immediate allergic reactions is poorly
documented. Three questions may be posed. What is the
prevalence of all reactions requiring a medical assistance
in the general population? What is the relative prevalence
of the severe reactions? What is the relative prevalence of
Epidemiological studies refer to different populations:
the general population, for whom the diagnosis data are
obtained through surveys or national registers (5–9),
hospital populations whose files are coded according to
the international classification of disease (ICD) directives
(10–12), patient cohorts at emergency units (EU) (13–17),
information from various networks such as The Study
Severe anaphylaxis is a systemic reaction affecting two or more organs or sys-
tems and is due to the release of active mediators from mast cells and basophils.
A four-grade classification routinely places ?severe? anaphylaxis in grades 3 and 4
(death could be graded as grade 5). Studies are underway to determine the
prevalence of severe and lethal anaphylaxis in different populations and the
relative frequencies of food, drug, latex and Hymenoptera anaphylaxis. These
studies will also analyse the risk arising from the lack of preventive measures
applied in schools (personalized management protocols) and from the insuffi-
cient use of self-injected adrenalin.Allergy-related conditions may account for
0.2–1% of emergency consultations. Severe anaphylaxis affects 1–3 per 10 000
people, but for the United States and Australia figures are even higher. It is
estimated to cause death in 0.65–2% of patients, i.e. 1–3 per million people. An
increased prevalence has been revealed by monitoring hospitalized populations
by reference to the international classification of disease (ICD) codes. The rel-
ative frequency of aetiological factors of allergy (food, drugs, insects and latex)
varies in different studies. Food, drug and Hymenoptera allergies are potentially
lethal. The risk of food-mediated anaphylaxis can be assessed from the number
of personalized management protocols in French schools: 0.065%. Another
means of assessment may be the rate of adrenalin prescriptions. However, an
overestimation of the anaphylaxis risk may result from this method (0.95% of
Canadian children). Data from the literature leads to several possibilities. First,a
definition of severe anaphylaxis should be agreed. Secondly, prospective, multi-
centre enquiries, using ICD codes, should be implemented. Moreover, the high
number of anaphylaxis cases for which the aetiology is not identified, and the
variation in aetiology in the published series, indicate that a closer cooperation
between emergency specialists and allergists is essential.
D. A. Moneret-Vautrin, M. Morisset,
J. Flabbee, E. Beaudouin, G. Kanny
Department of Internal Medicine, Clinical
Immunology and Allergology, University Hospital,
Nancy Cedex, France
Key words: Allergy Vigilance Network; epidemiology;
lethal; life-threatening anaphylaxis.
D. A. Moneret-Vautrin
Department of Internal Medicine
Clinical Immunology and Allergology
29 avenue du Mar?chal de Lattre de Tassigny
54035 Nancy Cedex
Accepted for publication 12 October 2004
Allergy 2005: 60: 443–451Copyright ? Blackwell Munksgaard 2005
the French Allergy Vigilance Network (4, 18). A subjective
estimate of the risk of severe anaphylaxis may be made
from the personalized management protocols for schools
(19), and from the number of adrenalin prescriptions (20).
The available data suffer from methodological short-
comings which limit the accuracy of the estimated
A total of 33 000 French people (a representative
sample of the French population under 60 years of age, at
the scale of 1/1000) answered a detailed questionnaire.
This indicated that 3.2% had suffered from food allergy.
About 5% were admitted to the EU and 17% required an
emergency home visit from a doctor. This represented an
incidence of immediate allergic reaction (requiring rapid
medical intervention) for 70 in every 10 000 people (5).
The rate of severe anaphylaxis is possibly much lower.
The prevalence of severe anaphylaxis may be estimated
by studies of national or district registers. Similar data
occur in different countries: from 0.5 to 1 per 10 000 in
the United Kingdom, Switzerland and the United States
(7–9; Table 1). A figure of 1.5 per 10 000 was given by a
multicentre epidemiological study of 481,000 hospitalized
patients between 1996 and 1998 in Sweden, Budapest,
Barcelona and Bombay (21).
Allergy-related emergencies could be better determined
from the files of EUs. They may represent from 0.2 to 1%
of attendances at EU in Australia, the United Kingdom
and France (Table 1; 13–17). Severe anaphylaxis was
diagnosed in 1–9 of 10 000 people attending EU in UK,
Australia and the USA (13). The figures for France and
Italy fall between these two extremes: 3/10 000 (16, 17;
Table 2). The frequency of allergy-related emergency in
children is debatable; identical to that for adults,
according to the report of Bohlke, but only 0.19 per
100 000 in MacDougal’s series (8, 22). This figure was
contested by Clark and Ewan who, considering only nut
allergy, proposed a figure at least six times higher (23).
Lethal anaphylaxis represents from 0.65 to 2% of cases
of severe anaphylaxis (6, 15), i.e. 1–3 deaths per million
people. A figure of 1500 deaths per year in the United
States has been suggested (24).
Continuous studies have been carried out by various
networks on allergy during anaesthesia and food and
drugs. The French retrospective study from the GERAP
established that 65.1% of 518 cases reported over 2 years
were grade 3 or 4 (4). These were declared after the
diagnosis had been confirmed by subsequent allergy
testing, although fatal cases were not recorded. The
prospective study on 328 000 subjects undergoing general
anaesthesia in Spain reported no fatal cases (25). A death
rate of 4.7% was recorded in Japan (26). Better know-
ledge of this sort of accident results in prompter
treatment and nowadays the progress made in resuscita-
tion techniques reduces the risk.
The French Allergy Vigilance Network, active in
France and Belgium since 2001 and involving 326
allergists, has recorded 229 cases of severe food-mediated
anaphylaxis over 3 years, 39% of which occurred in
children. Four deaths were reported, two children and
two adults (18).
A way of evaluating the risk of severe anaphylaxis in
children has been studied by using personalized manage-
ment protocols implemented in schools for severe food
allergies risk. The study carried out in 2002 on the whole
French school population (11 512 729 children) revealed
that 6.5 of every 10 000 children followed personalized
management protocols (19). There has been a fourfold
increase in the absolute number of personalized manage-
ment protocols since 1999 (27).
Most studies are too recent to allow changes in preval-
ence to be assessed although the incidence of food allergies
appears to be increasing. One has suggested a possible
fivefold increase in France between 1980 and 1995 (28).
British studies based on CIM-9, have reported a 250%
increase for severe anaphylaxis between 1995 and 1999,
with food anaphylaxis progressing in parallel (10, 12).
Overall, increasing allergy and anaphylaxis worries
both the public and medical body alike, to the extent that
Table 1. Epidemiological studies of anaphylaxis in hospitals
Characteristics (author, year, country)
Sheikh and Alves, 2000 and 2001 (10, 11),
United Kingdom Hospitalizations coded
according to ICD 9995.0
Wilson, 2000 (12), United Kingdom
according to ICD 10
Frequency of allergy-related emergencies
13.5 million from 1991 to 1995
2323–0.017% (frequency doubled
between 1991 and 1995)
Adults F/M : 1/2
0.5% of cases of anaphylaxis
1202 patients/2 years (1998 and 1999)
Frequency doubled between 1995 and 2000
Severe anaphylaxis (grades 3 and 4) 0.011% 0.00021% (two cases/million)
Lethality Eight deaths/10 years
1/800 000 children/year
Cause identified (%)
Other causes (%)
Moneret-Vautrin et al.
prescription of adrenalin far exceeds the objective risk of
severe anaphylaxis. In the United Kingdom, adrenalin
between 1990 and 1992 compared with those born
between 1981 and 1983 (29). In a Canadian population
of over 1 million, the prescription rate corresponded
to about 1% of the population, with a peak of 5% in
males aged 12–17 months (100–500 for 10 000 children)
Features of sublethal and lethal anaphylaxis dependent
In 1905, Finkelstein reported the death of a baby
re-challenged with milk. The death of an 18-month-old
child during re-challenge with peas was also reported by
von Starck in 1926 (30, 31). From as early as 1988,
attention was drawn to peanuts, fruit with shells and soya
(32–34). Then death following inhalation of steam from
shrimp and milk powder cooking was reported (35, 36).
From 1997, the risk of transmission, or onset of food
anaphylaxis following liver transplant was identified, and
deaths were reported (37, 38). Between 2002 and 2003, the
Allergy Vigilance Network recorded three deaths associ-
ated with peanut, soya and goat milk proteins (18). Severe
anaphylaxis may also be caused by rare allergens such as
boar meat, limpets, royal jelly, camomile and boldo,
alcohol, caffeine, gum arabic (39–46). The risk of severity
is shared by all foods (Fig. 1).
The most commonly affected age groups are adoles-
cents and young adults (2, 47, 48). This higher prevalence
than with adults may be related to the considerable
increase in peanut allergies reported for children 10 years
ago, and the severity in adolescents today may indicate an
increase in persistent allergies. There is a serious risk of
asthma in patients with food allergy. All the subjects in
Bock’s series were asthmatic (48). In a case-controlled
study, half the children with life-threatening asthma had a
food allergy, compared with 10% in the control group
(49). About 86% of deaths because of food-induced
anaphylaxis reviewed by Pumphrey presented with dys-
pnoea followed by respiratory arrest (50). Exercise could
be an aggravating factor (51). However, no fatal cases of
exercise-induced wheat-related anaphylaxis have been
reported, despite the relative frequency of allergy to
wheat. Masked allergens cause many cases of severe
anaphylaxis (32, 50). They concern 13% of the cases
reported by the Allergy Vigilance Network (18).
Severe drug-induced anaphylaxis
The lethal risk related to penicillin has been long known.
There is renewed interest in this subject because injectable
antibiotics are responsible for a large number of inci-
dences of anaphylaxis during anaesthesia (15%), taking
the third position after curare and latex (4, 52). They take
the first position in cases declared to the Allergovigilance
Network (Fig. 2). Deaths reported recently involved
iodine contrast agents, rocuronium, protease inhibitors
such as gabexate mesylate (53), aprotinin, cisplatin,
nonsteroidal anti-inflammatories (NSAID; diclofenac,
ketorolac), clindamycin, hydrocodone, methylpredniso-
lone, dexrazoxane, and agents used for investigations
such as patent blue, fluorescein, etc. (54–65). All routes of
administration are potentially lethal: intra-articular (66),
intra-uterine (67), intra-lymphatic (64), inhalation (68,
69), rectal (70, 71), topical skin application (72–74), and
even prick-tests (75). Anaphylactoid reactions without
defined immunological data have been associated with
similar risk: angiotens in converting enzyme (ACE)
inhibitors (76, 77), acetylcystein (78), nonhuman mono-
clonal antibodies (79, 80). Deaths involving latex are rare
In contrast to food anaphylaxis, drug anaphylaxis is
characterized by a high frequency of cardiovascular
collapse with rapid onset (within minutes), especially in
Table 2. Epidemiological studies of anaphylaxis in emergency units
(author, year, country)
Brown et al., 2001 (15),
Australia (SAU) (cases coded
according to ICD 9)
Stewart and Ewan,
United Kingdom (SAU)
Bellou et al., 2003 (17),
Pastorello et al., 2001 (16),
Helbling et al., 2004 (6),
Sample size 62 000 patients/year 55 000 patients/year32 000 patients/year38 685 patients in
1997 and 1998
940 000 patients
Frequency of allergy-related
(grades 3 and 4)
0.22% (144) 0.04%1% (324)
Adults F/M : 3/2
0.70% of cases of anaphylaxis
¼ 0.01% des patients
0.016% (24)0.037% (12)0.03% (12) 0.02% (226)
1.3% of cases of anaphylaxis
Cause identified (%)
Other causes (%)
Eight of nine
older patients (81). The risk factors for death include
cardiopathy associated with b-blocker therapy (82, 83).
A multicentre case–control study carried out in hospi-
tals in Sweden, Spain, Hungary and India, established a
grading of anaphylactic risk according to drug classi-
fications:outof 10 000
received antibiotics and NSAIDs, 3.2 penicillin, 3.5–
9.5 iodine contrast agents, dextran and pentoxyfilline,
37.8 streptokinase (82). There was a marked difference
in grading for vaccines and modified starches as
opposed to protease inhibitors and protamine (84, 85;
Severe anaphylaxis during anaesthesia
This condition has a special place amongst drug allergies
since it is regularly followed up by the GERAP (4).
Muscle relaxants (58.2%) remain the most common cause
with rocuronium the most implicated, followed by latex
(16.7%) and antibiotics. The incidence of anaphylaxis to
antibiotics has increased sevenfold since the first survey
carried out from 1984 to 1989 (4).
A prospective study carried out in 20 hospitals in
Catalonia from 1996 to 1997 collected data from over
328 000 anaesthetized patients. One case per 10 000
patients was recorded. About 56% were grade 3 or 4,
with high urinary methyl-histamine and/or tryptase levels
in 91% of grade 4 patients. No case of fatal anaphylaxis
was reported (25).
Severe anaphylaxis induced by Hymenoptera
This condition has appeared in all major studies and
represents from 11 to 29% of aetiologies, Switzerland
excepted (58%) (Tables 1 and 2). Deaths occur in a
range from 0.09 to 0.45/year/million (86). Anaphylaxis
caused by the stings of the hornet (Vespa crabro) is much
specific IT to venoms
Figure 2. Aetiologies of 100 cases of life-threatening drug ana-
phylaxis registered by the Allergo Vigilance Network over 2003/
Table 3. The rate of severe anaphylaxis depends on the type of drugs
Authors DrugsNumber of patients treatedAnaphylaxis (%) Lethality
Gupta et al. (113)
Cochrane and Bomyea (56)
Laxenaire et al. (85)
Iodine contrast agents
>90 000 injections
5231 intravenous infusions
>7 640 000 doses
0.05 (all grades)
0.05 (0.01% grades 3 or 4)
36% cases of anaphylaxis
Peanut and legumes
Figure 1. Clinical aspects and allergenic foods in life-threatening food anaphylaxis. Records of the Allergo Vigilance Network (2002,
2003, 2004 first semester).
Moneret-Vautrin et al.
more severe than that due to bees and Vespula species
(87). An interesting point is the particular risk related to
mastocytosis (88), and the fact that specific immuno-
therapy, normally very efficient, has not prevented death
Severe anaphylaxis related to ants, ticks, rattlesnake and hamster
Severe anaphylaxis related to the bites of Uruguayan and
Brazilian ants (Solenopsis richteri and S. invicta) in
the USA, and Australian ants (Mirmecia pilosula and
M. forficata) has been reported. About 17% of the
inhabitants of Georgia are sensitized to ants (90). About
32 deaths were recorded over 3 years, mostly in Florida
and Texas, and about 10 in Australia (90–92). Anaphy-
laxis to ticks (Ixodes ricinus, Argas reflexus, Rhiphicepha-
lus) may be more common than suspected (93–95). A
single case of anaphylactoid shock to a rattlesnake bite
draws the attention to the danger of removing the
pressure band, allowing venom proteins to reach the
systemic circulation (96). The popularity of various pets,
such as hamsters, raises new risks of anaphylaxis after
their bites, because of a sensitization to salivary proteins
Only one fatal case of idiopathic anaphylaxis has been
Severe anaphylaxis due to inhalants
Cases of systemic anaphylaxis associated with acute
laryngeal angio-oedema or respiratory arrest have been
triggered by inhalation of grass or cereal pollens (99–101).
A case of alpine slide anaphylaxis was the consequence of
a direct exposure to grass pollens through abraded skin
Severe anaphylaxis linked to parasitic diseases
Echinococcus granulosus forms hydatid cysts commonly
in liver and lungs. The rupture of these cysts induces a
potentially lethal anaphylaxis (103). Other cases have
been described linked to sensitization to Anisakis simplex,
a parasite of fish (104).
Differences in the figures of various authors regarding the
prevalence of severe anaphylaxis can be explained by the
fact that there is no consensus on the definition of the
condition. For some, acute asthma, a fall in blood
pressure and acute dyspnoea because of laryngeal angio-
oedema can be classified as severe anaphylaxis, since
those conditions can be fatal if not treated. For others,
the event must include cardio-respiratory arrest and
require at least two doses of adrenaline (22). Further-
more, it is of interest that of all the immediate-type
allergic reactions, the relative risk of severe anaphylaxis
for patients attending the EU is different in Anglo-Saxon
and Latin countries. In Anglo-Saxon countries, 29–41%
of patients attending EU presented with severe anaphy-
laxis, compared with only 3.7–8% of French and Italian
patients (Table 1). These statistics seem to indicate
different behaviour patterns amongst patients.
However, it seems that there is range of 0.5–3 cases of
severe anaphylaxis for every 10 000 people, and a death
rate of 1–3 per million. These figures are compromised by
deaths that are not always identified as anaphylaxis. For
example, in a case of allergy after liver transplant, it was
discovered later that the donor had died of food-induced
anaphylaxis (105). There are also cases of sudden death
possibly related to anaphylaxis, given the high level of
An increased prevalence over recent years may be
related to improved diagnosis because of the recording of
disease in hospitalized patients with classification accord-
ing to CIM-9 and -10. Moreover, in an ageing popula-
tion, there are more frequent intakes of drugs. There is
also an increased risk of allergy due to new food proteins
technologies, tending to increase the incidence of food
allergy and severe anaphylaxis.
Although great progress has been made with regard to
anaphylaxis during anaesthesia, the identification of the
causes remains variable, even in large cohort studies
(6, 14–16, 85; Tables 1, 2, 4).
The fear of the risk of anaphylaxis probably explains
why adrenalin prescriptions have increased, but a sound
basis for this prescription is questionable. It is certain that
there is a marked over-estimate of the risk of severe
anaphylaxis. If adrenalin is prescribed 200 times for each
real risk, the drug’s benefit/risk ratio may change
fundamentally. However, it is unfortunately also very
true that at the time of the emergency adrenalin is often
not available (6, 9, 107–111). It is noteworthy that in 28%
of cases, death results from cerebral anoxia following
collapse within a few hours to 3 days and not treated by
adrenalin in a timely fashion (47, 48, 50). This underlines
how much information and training is necessary for
emergency staff, other health professionals and the
general public with regard to first-line treatment of
anaphylaxis. Special attention has to be paid by school
personnel in charge of children at high risk of food
anaphylaxis (112). Emergency plans, including compre-
hensive guidelines, should be set in all countries. The
French school population includes 11 million children.
One of 1500 benefits from a care management project and
so far no lethal cases have been recorded in schools (19).
The available data are contradictory, on the one hand,
it seems that there is a steady increase in the frequency of
severe anaphylaxis, but diagnosis is now better and more
frequent, which is not the case for lethal anaphylaxis.
This affects 1–3 per million people and when applied to
the population of a country-like France suggests a
widespread ignorance of cases not benefiting from diag-
nosis. The proposed rate of 0.002% in the American
population (20 per million people) must be corroborated
by large-scale prospective studies (24), but it suggests
underlining the importance of diagnosis to all doctors.
There is a definitive agreement on the figures for incidence
of severe anaphylaxis (1–3 per 10 000 people) and for
lethal anaphylaxis (1–3 per million people). Risk related
to children cannot be assessed accurately since there are
insufficient studies in this population. Although allergy to
latex is rarely lethal, food and drug allergies provide the
most data. Unlike allergies related to Hymenoptera,
where specific immunotherapy can effectively counteract
the risk of recurrence, there is currently no prophylaxis or
specific treatment for food and drug allergies.
Emergency health care professionals and patients
should be better informed, so that emergency treatment
can be followed by a complete allergy diagnosis. Close
cooperation between emergency health care professionals
and allergists is essential and should evolve gradually in
the same way as that between anaesthetists and allergists.
Such cooperation could allow in-depth analysis, seeking
factors predictive of seriousness. A high level of sensiti-
zation has not been correlated with the severity of allergic
reactions. Other possible factors might identify particu-
larities of the organism, prevailing over the specific nature
and the dose of food allergens.
More accurate epidemiological data should now
become available from the coding of hospital files using
ICD 10: T 78.0 C A food, T 88.6 C A medicinal products,
T 80.5 C A serum, T 78.2 C A not specified (idiopathic),
J 46 serious acute asthma, T 78.3 laryngeal oedema. This
should enable close comparison of countries, based on
prospective, multicentre studies. Limiting these studies to
hospital populations would be, however, insufficient.
Complete data regarding severe anaphylactic reactions
could be obtained from networks to which all allergists
might report cases with their aetiologies. The Allergy
Vigilance Network, now including 326 French and
Belgian allergists, has been implementing this process
since its foundation in 2001 and might open the way to a
European network (18).
Table 4. Causes of severe anaphylaxis.
Author, year, country
Dibs and Baker,
1997 (107), USA
Yocum et al., 1999 (108),
Cianferoni et al., 2001 (109),
Pumphrey, 2000 (50),
Mullins, 2003 (9),
Sample size 50 children retrospective study
over 5 years
154/cohort of 1255 patients
followed up from 1983 to 1987
107 patients retrospective study
over 11 years
164 patients National
50 (half during anaesthesia)
Causes identified (%)
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phylactique de certains venins. C R
Se ´ ances Mem Soc Biol Paris
2. Sampson HA, Mendelson L, Rosen JP.
Fatal and near-fatal anaphylaxis to
food in children and adolescents. N
Engl J Med 1992;327:380–384.
3. Ring J, Behrendt H. Anaphylaxis and
anaphylactoid reactions. Clin Rev
Allergy Immunol 1999;17:387–399.
4. Mertes PM, Laxenaire MC, Alla F.
Groupe d?e ´ tudes de re ` actions anaphyl-
actoı¨des peranesthe ´ siques. Anaphylac-
tic and anaphylactoid reactions
occurring during anesthesia in France
in 1999–2000. Anesthesiology
5. Kanny G, Moneret-Vautrin DA,
Flabbee J, Beaudouin E, Morisset M,
Thevenin F. Population study of food
allergy in France. J Allergy Clin
6. Helbling A, Hurni T, Mueller LR,
Pichler WJ. Incidence of anaphylaxis
with circulatory symptoms: a study
over a 3-year period comprising 940,000
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Clin Exp Allergy 2004;34:285–290.
7. Peng MM, Jick H. A population-based
study of the incidence, cause, and
severity of anaphylaxis in the United
Kingdom. Arch Intern Med 2004;164:
8. Bohlke K, Davis RL, De Stefano F,
Mary SM, Braun MM, Thompson RS.
Epidemiology of anaphylaxis among
children and adolescents enrolled in a
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9. Mullins RJ. Anaphylaxis: risk factors
for recurrence. Clin Exp Allergy
10. Sheikh A, Alves B. Hospital admissions
for acute anaphylaxis: time trend study.
11. Sheikh A, Alves B. Age, sex, geo-
graphical and socio-economic varia-
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analysis of four years of English hos-
pital data. Clin Exp Allergy
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12. Wilson R. Upward trend in acute ana-
phylaxis continued in 1998–9. BMJ
13. Klein J, Yocum MW. Underreporting
of anaphylaxis in a community emer-
gency room. J Allergy Clin Immunol
14. Stewart A, Ewan PW. The incidence,
aetiology and management of anaphy-
laxis presenting to an accident and
emergency department. Q J Med
15. Brown A, Mckinnon D, Chu K.
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review of 142 patients in a single year.
J Allergy Clin Immunol 2001;108:861–
16. Pastorello E, Rivolta F, Bianchi M,
Mauro M, Pravettoni V. Incidence of
anaphylaxis in the emergency depart-
ment of a general hospital in Milan.
J Chromatol B Biomed Sci Appl
17. Bellou A, Manel J, Samman-Kaakaji
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19. Moneret-Vautrin DA, Romano MC,
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Parisot L et al. The individual reception
project (IRP) for anaphylactic emer-
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French overseas territories in 2002.
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20. Simons F, Peterson S, Black CD. Epi-
nephrine dispensing patterns for an out-
of-hospital population: a novel ap-
proach to studying the epidemiology of
anaphylaxis. J Allergy Clin Immunol
21. International Collaborative Study of
Severe Anaphylaxis. An epidemiologic
study of severe anaphylactic and ana-
phylactoid reactions among hospital
patients: methods and overall risks.
22. MacDougal CF, Cant AJ, Colver AF.
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childhood? The incidence of severe and
fatal allergic reactions across the UK
and Ireland. Arch Dis Child
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24. Neugut A, Ghatak AT, Miller RL.
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Arch Intern Med 2001;161:15–21.
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26. Mitsuhata H, Hasegawa J, Matsumoto
S, Ogawa R. The epidemiology and
clinical features of anaphylactic and
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by Japan Society of Anesthesiology.
27. Moneret-Vautrin DA, Kanny G, Mor-
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Parisot L et al. Food anaphylaxis in
schools: evaluation of the management
plan and the emergency kit. J Allergy
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28. Moneret-Vautrin DA, Kanny G.
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29. Morritt J, Aszkenasy M. The anaphy-
laxis problem in children: community
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30. Finkelstein A. Kuhmilch als Ursache
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